- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $6,606.93
| Facility | | $1,288.25 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $3,019.95
| Professional | | $1,621.81 | $2,089.30 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,754.23 / $3,090.30
| Professional | | $1,949.84 | $2,754.23 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,454.71 / $6,309.57
| Facility | | $346.74 | $2,454.71 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,238.72 / $24,547.09
| Professional | | $1,659.59 | $2,238.72 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,090.30
| Professional | | $1,548.82 | $2,041.74 | $3,090.30 |